Online registration Please fill out ALL fields of this form. If you have any questions or concerns you’d like to discuss with us, please call us on 818-758-3832. Please note that one registration form is needed per child. We look forward to a wonderful year of learning and growth. Student Profile First Last Hebrew Name DOB Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Dec. Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 School Grade Entering Grade Entering Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Hebrew Reading Proficiency None Somewhat Well Previous Jewish Education Yes No Where? Is the natural mother of the child Jewish? Yes No Have there been any conversions or adoptions in the family? If Yes, please explain. Parent Information Father's Name Phone Mother's Name Phone Address City State Zip Email Address Emergency Information Emergency Contact 1 Phone Emergency Contact 2 Phone General info Which program do you prefer? Sundays, 9:30 to 11:30 am Tuesdays, 3:10 to 5:10 pm Does your child have any difficulties with general studies? Yes No To enhance our curriculum, we have school events and programs. Would you be willing to assist in event planning? Yes No Would you like to be a class mother? Yes No Would you or your teenage child volunteer to help a Special Needs child in our community with the Friendship Circle program? Yes No I would you like to make a donation to the Hebrew School Scholarship fund Please email me more information regarding Chabad activities CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed. Payment Information I would like to pay a one-time installment of $1,050 Payment amount $1050 Name on card First Last Credit Card Number Billing Address Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12 Month... 2017 2018 2019 2020 2021 2022 2023 2024 Year... 2025 2026 2027 2028 2029 2030 CVV As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes. If for any reason you decide to cancel during the year, you will be refunded from the beginning of the next month. There are no refunds after April 1st. I Accept Name: Initials: We look forward to a wonderful year of learning and growth! This page uses 128 bit SSL encryption to keep your data secure.